Provider Demographics
NPI:1518497445
Name:ROGGOW, GINA CLAIRE (LPC)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:CLAIRE
Last Name:ROGGOW
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:CLAIRE
Other - Last Name:UDING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1129 MACKLIND AVE. - MARY STEELE
Mailing Address - Street 2:1129 MACKLIND AVE.
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110
Mailing Address - Country:US
Mailing Address - Phone:314-534-0200
Mailing Address - Fax:
Practice Address - Street 1:16216 BAXTON RD ST. LOUIS BEHAVIORAL MEDICINE INSTITUTE
Practice Address - Street 2:16216 BAXTON RD SUITE 205
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017
Practice Address - Country:US
Practice Address - Phone:314-534-0200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-13
Last Update Date:2022-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014044598101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional